Incidence and Severity of COVID-19 in HIV-Positive Persons Receiving Antiretroviral Therapy
Authors: Boghuma Titanji, Alfonso C. Hernandez-Romieu, Max W. Adelman
Journal: Annals of Internal Medicine (2021)

LettersApril 2021Incidence and Severity of COVID-19 in HIV-Positive Persons Receiving Antiretroviral TherapyFREEBoghuma Titanji, MD, MSc, PhD, Alfonso C. Hernandez-Romieu, MD, MPH, Max W. Adelman, MD, MScBoghuma Titanji, MD, MSc, PhDEmory University School of Medicine, Atlanta, GeorgiaSearch for more papers by this author, Alfonso C. Hernandez-Romieu, MD, MPHEmory University School of Medicine, Atlanta, GeorgiaSearch for more papers by this author, Max W. Adelman, MD, MScEmory University School of Medicine, Atlanta, GeorgiaSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/L20-1398 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail TO THE EDITOR: We read with interest del Amo and colleagues' article (1) on the incidence and severity of coronavirus disease 2019 (COVID-19) in a large cohort of persons living with HIV (PLWH) in Spain. The authors examined COVID-19 outcomes stratified by antiretroviral therapy (ART) regimen. They concluded that PLWH receiving tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC) had better outcomes than those receiving either tenofovir alafenamide (TAF)/FTC or abacavir (ABC)/lamivudine (3TC).Although these findings are interesting, the authors did not control for comorbidities—key confounders that may have substantially affected these results. Non–AIDS-related comorbidities, including cardiovascular disease, chronic kidney disease, and diabetes, have all been associated with both increased risk for severe acute respiratory syndrome coronavirus 2 infection and worse clinical outcomes from COVID-19 (2).In addition, non–AIDS-related comorbidities are highly prevalent among PLWH (3). The results presented do not account for whether persons in the “protected” TDF/FTC group simply had fewer comorbidities than those in the TAF/FTC and ABC/3TC groups. The relationship between comorbidities and ART is bidirectional.Several ART regimens are most appropriate for patients with few comorbidities. For example, TDF is not recommended for patients with chronic kidney disease. Furthermore, the choice of ART may directly affect the incidence of non–AIDS-related comorbidities. Recent studies have reported significant metabolic abnormalities and weight increases in patients receiving TAF-containing regimens compared with those receiving TDF-containing regimens (4), and ABC has been independently associated with increased risk for cardiovascular events (5).As such, patients in the TDF/FTC group in this study were likely to have had a lower prevalence of non–AIDS-related comorbidities that confer high risk for COVID-19 and related adverse outcomes. We would be interested in seeing the prevalence of non–AIDS-related comorbidities stratified by ART group in this cohort, as well as a multivariable analysis that controlled for these comorbidities. These factors would elucidate whether patients receiving TDF/FTC were protected because of their ART regimen or because they had fewer non–AIDS-related comorbidities.In light of recent experiences with hydroxychloroquine for treatment of COVID-19, caution is warranted when extrapolating the data presented in this study to support the hypothesis that TDF/FTC may be useful for preexposure prophylaxis and treatment of COVID-19. Such assertions may fuel off-label use of antiretroviral drugs for COVID-19 and have serious implications for drug resistance in undiagnosed HIV infection and drug shortages for PLWH.References1. del Amo J, Polo R, Moreno S, et al; The Spanish HIV/COVID-19 Collaboration. Incidence and severity of COVID-19 in HIV-positive persons receiving antiretroviral therapy. A cohort study. Ann Intern Med. 2020;173:536-41. [PMID: 32589451]. doi: 10.7326/M20-3689 LinkGoogle Scholar2. Richardson S, Hirsch JS, Narasimhan M, et al; the Northwell COVID-19 Research Consortium. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area. JAMA. 2020;323:2052-9. [PMID: 32320003] doi: 10.1001/jama.2020.6775 CrossrefMedlineGoogle Scholar3. Marcus JL, Leyden WA, Alexeeff SE, et al. Comparison of overall and comorbidity-free life expectancy between insured adults with and without HIV infection, 2000-2016. JAMA Netw Open. 2020;3:e207954. [PMID: 32539152] doi: 10.1001/jamanetworkopen.2020.7954 CrossrefMedlineGoogle Scholar4. Venter WDF, Moorhouse M, Sokhela S, et al. Dolutegravir plus two different prodrugs of tenofovir to treat HIV. N Engl J Med. 2019;381:803-15. [PMID: 31339677] doi: 10.1056/NEJMoa1902824 CrossrefMedlineGoogle Scholar5. Choi AI, Vittinghoff E, Deeks SG, et al. Cardiovascular risks associated with abacavir and tenofovir exposure in HIV-infected persons. AIDS. 2011;25:1289-98. [PMID: 21516027] doi: 10.1097/QAD.0b013e328347fa16 CrossrefMedlineGoogle Scholar Comments 0 Comments Sign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: Boghuma Titanji, MD, MSc, PhD; Alfonso C. Hernandez-Romieu, MD, MPH; Max W. Adelman, MD, MScAffiliations: Emory University School of Medicine, Atlanta, GeorgiaDisclosures: Authors have reported no disclosures of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=L20-1398. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoIncidence and Severity of COVID-19 in HIV-Positive Persons Receiving Antiretroviral Therapy Julia del Amo , Rosa Polo , Santiago Moreno , Asunción Díaz , Esteban Martínez , José Ramón Arribas , Inma Jarrín , and Miguel A. Hernán , and for The Spanish HIV/COVID-19 Collaboration* Incidence and Severity of COVID-19 in HIV-Positive Persons Receiving Antiretroviral Therapy Julia del Amo , Rosa Polo , Santiago Moreno , Asunción Díaz , Esteban Martínez , José Ramón Arribas , Inma Jarrín , Miguel A. Hernán Metrics April 2021Volume 174, Issue 4 Page: 580-581 ePublished: 20 April 2021 Issue Published: April 2021 Copyright & PermissionsCopyright © 2021 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...